1. THE INITIAL CHALLENGE: THE ROLE OF SKILLED BIRTH ATTENDANTS IN SAVING THE LIVES OF MOTHERS AND BABIES

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1 TheEvol ut i onofpr ogr amsdesi gned t oi ncr easeut i l i z at i onofski l l edbi r t h At t endancei nni ger i a Sci enceofdel i ver ycasestudy J anuar y2014

2 ACKNOWLEDGEMENTS This case study was prepared and researched by Anna Williams. Robert K. Yin aligned some of the materials in line with the structure and flow of a set of Science of Delivery pilot case studies prepared during the period of May to December Many individuals contributed to this case study, starting with the 18 interviewees who provided context, detail, and insight. The following individuals contributed additional assistance: Olufemi Adegoke, Ayodeji Akala, Aarushi Bhatnagar, Arianna Legovini, Kelechi Ohiri, Ayodeji Oluwole Odutolu, Ugo Okoli, Dinesh Nair, Muhammad Ali Pate, and Hong Wang. Special acknowledgements are due to Marcus Holmlund and Dr. Robert K. Yin for their in-depth reviews and editorial support. 1

3 ACRONYMS ANC CHEW CCT DIME FCT FMoH HSDP IE IMNCH LGAs MCH MNCH MOU MDG MSS MMR NMR NPHCDA NSHIP NSHDP PHC PBF PMTCT PNC RBF SBA SOML SURE-P TBA VHW WDC Antenatal Care Community Health Extension Worker Conditional Cash Transfer World Bank s Development Impact Evaluation Group Federal Capitol Territory Federal Ministry of Health Health Systems Development Project Impact Evaluation Integrated Maternal, Newborn, and Child Health Local Government Areas Maternal and child health Maternal, Newborn, and Child Health Memorandum of Understanding Millennium Development Goal Midwives Service Scheme Maternal Mortality Ratios Neonatal Mortality Ratios National Primary Health Care Development Agency Nigeria State Health Investment Project National Strategic Health Development Plan Primary Healthcare Centre Performance-Based Financing Prevention of Mother-to-Child Transmission of HIV/AIDS Postnatal Care Results-Based Financing Skilled Birth Attendant Saving One Million Lives Subsidy Reinvestment and Empowerment Programme Traditional Birth Attendants Village Health Worker Ward Development Committee 2

4 1. THE INITIAL CHALLENGE: THE ROLE OF SKILLED BIRTH ATTENDANTS IN SAVING THE LIVES OF MOTHERS AND BABIES Worldwide, the vast majority of pregnancies and births over 85 percent can occur safely and without fatal consequence to mother or child if the right support systems are in place. Up to 15 percent of all births are complicated by potentially fatal conditions, some of which are unpredictable, but almost all of which are treatable. 1 Skilled birth attendants (SBAs) save the lives of mothers and babies. Utilization of SBAs is considered the single most critical intervention for ensuring safe motherhood and is vital to preventing perinatal deaths, the majority of which occur during labor and delivery or within the first 48 hours after delivery. 2 SBAs are individuals trained and proficient in midwifery skills, namely doctors, midwives, and nurses. These individuals have the skills necessary to manage normal deliveries and diagnose, manage, or refer obstetric complications. Evidence from many countries 3 indicates that SBAs functioning in or very close to communities can have a dramatic impact on the reduction of maternal and neonatal mortality. 4 This case study focuses on the SBA utilization rate, defined as the percent of live births attended by SBAs. 1.1 The Case Study: The Evolution of Programs to Increase the Utilization of Skilled Birth Attendants This case study focuses on programs designed to increase the utilization of skilled birth attendants (SBAs) as well as other maternal and child health (MCH) programs that complement SBAs to provide comprehensive improvements in public health care delivery for mothers and children. (See Exhibit 1 for definitions of SBA and other terms related to MCH.) The objective of this case study is to learn how and why efforts to save the lives of mothers and babies in Nigeria have changed over the past several years, and specifically to understand the role of evidence-based program designs; how evidence, experience, and learning can inform the evolution of programming efforts. The case study also presents data that show increases in SBA utilization and corresponding decreases in maternal mortality associated with the implementation of MCH programs implemented since The efforts supporting SBA utilization are still unfolding, and will be for the next several years. Impact evaluations (IEs) of the current programs are underway, as are many other IEs of related programs, all requested by and being implemented in full collaboration with the Government of Nigeria. IEs rely on statistically valid approaches based on counterfactual analysis that can attribute outcomes to particular interventions. The new approach to IE in Nigeria s health sector comes with support for strengthening program design from the outset, as well as provision of interim results and impact information to support mid-course adjustments. This approach to IE is a positive departure from traditional retrospective IE with regard to supporting improved delivery on the whole. The work in Nigeria to save the lives of mothers and babies is reported to be unprecedented, both in the 1. United Nations Population Fund (UNFP). Skilled Attendance at Birth. Accessed June 30, 2013, 2 Ibid. 3 China, Cuba, Egypt, Jordan, Malaysia, Sri Lanka, Thailand, and Tunisia, among others. 4 United Nations Population Fund (UNPF). Skilled Attendance at Birth. 3

5 scale of investment and in the iterative, research-based approaches that are improving health outcomes in one of the most complex countries in the world. Still, these efforts face many uphill battles, including widespread disparity in socioeconomic status across the country and political upheaval that threatens stability and security in certain areas. Some experts are skeptical that any efforts can transform health care delivery in Nigeria at this time. Those who are most familiar with the work acknowledge the challenges, and yet persevere with a deep level of commitment to improving primary health care in a country that is, in their minds, too important to ignore. The stakes in terms of lives are simply too high. They do not want to wait for the ideal opportunity or moment when hundreds of thousands of mothers and babies die each year for preventable reasons. In the words of Dr. Muhammad Ali Pate, the recently departed former Minister of State for Health in Nigeria: "The country is too important to not fight the fight. I remain optimistic about the future of the country because you cannot afford not to." 1.2 Case Study Questions The case study addresses two questions: Q1. What changes have been made to programs intended to save the lives of mothers and babies in Nigeria, from 1999 to the present? and; Q2. How have the newer programs drawn from learning and adaptation from research evidence and earlier experiences? To provide the information related to these questions, Sections 3 and 4 of the case study describe the programs implementation experiences. Wherever relevant, the presentation also calls attention to various delivery features: inflection points (actions when implementation moved critically forward or was thwarted); pain points (resistant conditions or groups); adaptiveness/refinement (how patterns of implementation changed in some helpful way); feedback loops (how ongoing actions influenced or changed earlier plans); and behavior change (changes in client/citizen outcomes or in organizational practices or policies). Drawing upon the implementation experiences, Section 5 of the case study then summarizes the responses to the two case study questions. 1.3 Methods and Caveats The case study researcher collected primary data through 18 interviews conducted between May and October 2013 with experts located in Nigeria and the US. Only a few of these experts are US-based, and they all have extensive experience in Nigeria. The researcher also directly observed a four-day workshop in May 2013 called Impact Evidence and Action to Save Lives in Nigeria convened by the World Bank s Development Impact Evaluation Group and sponsored by the Bill and Melinda Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the World Bank-administered Africa Regional Learning Program. The workshop involved approximately 80 health experts from Nigerian federal and state agencies. Secondary data sources for the case study included published studies, publicly-available data, and other information provided to or identified by the researcher. The researcher synthesized all relevant information and triangulated data from various sources in order to establish the findings in this case study. 4

6 At the same time, the case study was conducted under highly constrained time and resource conditions. These conditions led to limited field access to the desired variety of sources of evidence, including minimal availability for scheduling interviews with key officials or for obtaining permissions to analyze relevant agency archival and documentary data. The main field informants also did not have a chance to provide thorough feedback on the draft or early versions of the case study. Accordingly, although the resulting case study provides an accurate rendition of the main events and actions, differing perspectives about the implementation process, including rival renditions of the process, have not necessarily been represented. In addition, a substantial amount of work done over the past few decades on MCH in Nigeria is not covered in this case study because of the time limitations. The work done by many states, local governments, international organizations, and domestic organizations has undoubtedly contributed to the overall body of knowledge and improvements in delivery of many public health programs in Nigeria, including those discussed in this case study. 5

7 Textbox 1. Definitions Related to Maternal and Newborn Health Terms associated with maternal and newborn mortality rates are becoming more refined over time. Below are several of the commonly used terms on this topic. Antenatal: During or relating to pregnancy; prenatal. Intrapartum-related neonatal death: Neonatal deaths, previously called birth asphyxia or asphyxiarelated neonatal deaths. Intrapartum stillbirth: Late fetal death during labor, clinically presenting as fresh stillbirth. Maternal Mortality Ratio (MMR): The ratio of the number of maternal deaths during a given time period per 100,000 live births during the same time period. A maternal death refers to a female death from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy. Neonatal: Relating to the first 28 days of an infant's life. Also known as newborn. Neonatal death: See intrapartum-related neonatal death. Neonatal Mortality Ratio (NMR): The ratio of the number of neonatal deaths during a given time period to 1,000 live births during the same time period. Perinatal: The period immediately before and after birth. Depending on the definition, it starts at the 20th to 28th week of gestation and ends 1 to 4 weeks after birth. Postnatal: The time period right after birth. More specific definitions for this time period (e.g., one week or month after birth) are sometimes used. Skilled Birth Attendance: Skilled birth attendants working within an enabling environment or health system capable of delivering appropriate emergency obstetric care for all women who develop complications during childbirth. Skilled Birth Attendant: Individuals who are trained and proficient in midwifery skills, namely doctors, midwives, and nurses. Skilled Birth Attendant Utilization Rate: Percentage of live births attended by a skilled birth attendant. Stillbirth: The death of a fetus at any time after the twentieth week of pregnancy. Also referred to as intrauterine fetal death. 2.1 Geopolitical Conditions 2. THE NIGERIAN CONTEXT Nigeria is a large and complex country the largest in Africa and seventh-largest in the world. Nigeria s population is approximately 160 million and is growing at a rate of approximately 2.5 percent per year. 6

8 By 2015, the population is projected to be 63 percent larger than it was in despite high mortality rates among vulnerable populations, including mothers, children, and those living with HIV/AIDS. Nigeria is comprised of 36 states and a Federal Capital Territory, divided into six geopolitical zones (see Figure 1). Within the states are 774 local government areas (LGAs), with each comprising wards overseen by ward development committees. Figure 1. Map of Nigeria Showing the 36 States and Federal Capital Territory as well as the Six Geopolitical Zones Source: World Journal of Cardiology. 4(12): December 2012 Nigeria is one of the world s largest oil producers, resulting in relatively high revenues for the government (as compared to other countries in Sub-Saharan Africa) and pockets of private wealth, particularly in the south where the oil production occurs. Although Nigeria on the whole is classified as lower-middle income, as of 2007, 60 percent of the population lived below the US$1.25 per day poverty line and 80 percent lived on less than US$2.00 per day. 6 Six in 10 women of childbearing age live in the country s three northern zones, where the population is predominantly Muslim. The southern half of the country is predominantly Christian, and although there are pockets of impoverished areas in the south, poverty rates in the south are lower than in the north. In essence, Nigeria is divided economically, religiously, and geographically. 5 ibid. 6 ibid. 7

9 Local governments are responsible for primary health care in Nigeria. States are responsible for secondary care and the federal government under the direction of the Federal Ministry of Health (FMoH) is responsible for tertiary care. 7 This arrangement has historically led to poor coordination and integration between levels of care and a weak and disorganized health system with widely varying patterns of outcomes Maternal and Newborn Mortality in Nigeria Nigeria has two percent of the world s population and 10 percent of the world s maternal and underfive deaths. Approximately 950,000 children under five years of age die each year, most from preventable causes, including malnutrition and preventable infectious diseases (malaria, pneumonia, and diarrheal diseases). Of these deaths, over 240,000 are newborns. Causes include intrapartumrelated injury, complications of pre-term birth, and severe infections. An estimated 70 percent of these newborn deaths could be prevented using existing health care packages. Each year, 33,000 mothers die (from among the global total of 529,000) from pregnancy-related complications; three-quarters of these could be prevented with existing health interventions. 9 Within Nigeria, MCH statistics vary widely, as exemplified by the utilization of primary maternal and child health care services shown in Figure 2, and the maternal mortality ratio (MMR) shown in Figure 2. The MMR is the highest in the north (particularly the North East zone) and the lowest in the South West zone. The MMR is associated with regional variations in poverty level and also differences in urban and rural access to health care. Alarming MMRs, particularly in the poorest regions of the country and rural areas, and other equally troubling MCH indicators, have garnered a tremendous amount of international aid assistance to support MCH programs in Nigeria. In fact, when measured by absolute funding, Nigeria receives more international development assistance for MCH than any other country. (See discussion in Annex 4, Funding for Maternal, Newborn, and Child Health in Nigeria.) Still, what the international community spends on improving MCH in Nigeria is dwarfed by what Nigeria itself spends: more than 95 percent of all investments in MCH in Nigeria come from the Government of Nigeria. Within this context, and given the stakes in terms of lives (and financial investments), it is critically important to make progress where possible through well-understood, basic health interventions that can make dramatic differences in MCH outcomes. Historically, health care utilization has varied tremendously by socioeconomic status, with the wealthiest Nigerians participating in far more MCH services, including antenatal care and utilizing SBAs, than the poorer Nigerians. (See Figure 2.) Figure 2. The States of Nigeria and Their Maternal Mortality Ratios 7 Federal health financing flows from a federation account allocated between levels of government according to a formula that retains approximately half of the funds at the federal level, with the split between states and local governments at approximately 50 percent at each level. Federal health funds are not earmarked by sector and the states and local governments are not constitutionally required to provide budget and expenditure reports to the federal government. Source: Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate, MA (2012) 8 Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA (2012) The Midwives Service Scheme in Nigeria. PLoS Med 9(5): e doi: /journal.pmed Republic of Nigeria. SURE-P MCH Project Office. Mobilizing Access to Health Care Services for Mothers and Infants (MAMA). Issue 1. April

10 Key: Red (North East and North West), very high MMR; yellow (North Central and South South), high MMR; green (South East and South West), moderately high MMR. Source: Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA (2012) Figure 3. Use of Primary MCH Care Services among the Lowest and Highest Population Quintiles Source: 2008 Nigerian Demographic and Health Survey 9

11 3. EFFORTS TO PROMOTE THE UTILIZATION OF SKILLED BIRTH ATTENDANTS: THE OLD PARADIGM 3.1 Actions Taken The Nigerian government began promoting efforts to improve local health delivery including MCH in the 1980s while the country was still under military rule. In 1986 the FMoH introduced primary healthcare centers (PHCs). National guidelines were developed for PHC planning and implementation, including training curricula for traditional birth attendants (TBAs) and village health workers. 10 The PHC guidelines were not well received, and this and other challenges led to the collapse of the PHC program as it was originally designed [pain point]. 11 Beginning in the 1990s the federal government undertook several efforts to increase primary health care. In addition to spending its own financial resources on supporting primary care through building PHCs, the federal government continued to provide funding to states and Local Government Areas (LGAs) to support primary health care, including support for MCH. Many policies and programs were initiated (see Exhibit 2) during this period, supplemented in many cases by large amounts of international assistance [inflection point]. One example of an international program intended to improve provision of health care during this period was the Health Care Systems Development program (HCSD). Nigeria initially borrowed over US$100 million from the World Bank and African Development Bank HCSD to assist the Nigerian health authorities in their efforts to both address the serious deterioration in the delivery of basic health care services following decades of neglect and to build institutional capacities [inflection point]. 12 Under HCSD (and other programs), FMoH disbursed funds equally across the country regardless of the variations in need or capacity. Although approximately 20,000 PHCs were established, few PHCs were adequately stocked or staffed, and public confidence in PHCs declined to the point that a parallel private health care system began to rapidly grow and gain popularity [pain point]. 10 The TBAs were to assist in-home deliveries while the VHWs were to provide basic curative care and health education. 11 TWG- NSHDP/Health Sector Development Team. July World Bank (2012). ICR for HSDP II 10

12 Textbox 2. Timeline of MCH-Related Policies and Programs in Nigeria The three programs that include targeted SBA utilization efforts appear in the shaded rows. These three efforts (MSS, NSHIP, and SURE-P MCH) are the primary examples of the new approaches to design and delivery of services in this area. The list below does not reflect all MCH policies and programs, of which there have been many over the past 20 years sponsored by agencies within Nigeria and by international partners Introduction of Primary Healthcare Centers 1987 Launch of Safe Motherhood Initiative 1988 National Health Policy 2001 National Reproductive Health Policy and Strategy Ward Minimum Healthcare Package National Policy on Food and Nutrition 2003 National HIV/AIDS and PMTCT Policy and Strategy 2004 Revised National Health Policy Health Sector Reform Programme ( ) National Plan for Action on Food and Nutrition 2005 National Policy on Infant and Young Child Feeding 2006 National Child Health Policy Accelerated Child Survival and Development: Strategic Framework & Plan of Action Roadmap for Accelerating the Achievement of the MDGs Related to Maternal and Newborn Health 2007 Approval of the Integrated Maternal Newborn and Child Health (IMNCH) Strategy Transition from old to new paradigm (2008) Includes high-level commitment to incorporating impact evaluation into program design and implementation to gain evidence of what works and allow for corresponding adjustments to design and implementation Launch of Midwives Service Scheme (MSS) (SBA focused) 2010 National Strategic Health Development Plan Launch of Nigeria State Health Investment Project (NSHIP) (includes SBA component) 2011 Launch of President s Transformation Agenda 2012 Launch of SURE-P MCH (includes SBA component) Launch of the Save One Million Lives Initiative (SURE-P MCH and other MCH programs are now considered to be under the Save One Million Lives Initiative umbrella) By the mid-2000s, health care indicators had uniformly deteriorated, including a 2003 decline in SBA utilization [feedback loop]. This, combined with growing pressure to achieve the MDGs and increased funding from international sources, caused the FMoH to develop new programs in an effort to regain the momentum seen earlier in the decade. 11

13 During , the government implemented the Health Sector Reform Programme (HSRP). Although the HSRP resulted in a number of policy and legislative initiatives, including the National Health Policy review, the National Health Bill changes to the National Health Insurance Scheme, and other efforts to strengthen disease programs and improve the quality of care in tertiary health facilities, much of the underlying weaknesses and constraints of the health sector persisted as of Work funded by loans and donations from the international community continued through the 2000s. The World Bank- and Africa Development Bank-funded HSDP continued to build the primary health care system nationwide through additional loans, bringing the total loan for HSDP over the course of more than a decade to over US$200 million. Despite the significant investment from this project alone, PHC utilization continued to be low, services provided at PHCs were considered marginal, and the project s Implementation Completion and Results Report identified that outcomes, Bank (donor) performance, and borrower performance to all be moderately unsatisfactory [pain point]. This report also found the risk to development outcome to be high. 13 Throughout the 2000s public health services suffered for a variety of other reasons as well [pain point]. Inadequate funding and stewardship of resources hampered performance at all levels of the health care system, resulting a high-cost burden to households for health expenditures a problem only exacerbated in impoverished areas. 14 Quality of care in health facilities was typically low, marked by lack of basic resources such as power, water, equipment, and medication. 15 Nigerians in most rural areas lacked access to healthcare, and those who did generally speaking still did not have access to 24- hour health services. In the words of Nigerian officials, toward the end of the decade Nigeria faced a crisis in human resources for health in the form of health worker shortages, requiring an immediate and significant increase in the number of health workers, particularly in grossly underserved rural areas. 16 On the whole, there was widespread recognition that progress on provision of primary health care was falling short of potential, at a high cost of lives needlessly lost Trends in SBA utilization and MMR during this period The SBA utilization trends reported between 1990 and 2008 are widely cited, and therefore they warrant review and also some level of scrutiny. These trends are reported first for Nigeria alone and then in the context of regional and global trends during this period. Reported Trends in Nigeria. At the macro, national-average level the reported data show an overall increase in SBA utilization from 31 percent in 1990 to 39 percent in 2008 (see Figure 4). However, these data also show a notable decrease in utilization between 1999 (43 percent) and 2003 (35 percent) with no clear explanation [feedback loop]. Unfortunately, no rigorous analysis of the causes of the trends in either direction was conducted to explain why changes were occurring, assuming the data were robust to begin with. 13 World Bank (2012). ICR for HSDP II. 14 Federal Republic of Nigeria, Federal Ministry of Health, Save the Children, JHPIEGO (2011) 15 Ibid. Also supported by descriptions of the system at this time given by several experts during the interviews conducted for this case. 16 Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA (2012) 17 All experts interviewed for this case study who reflected on this time period recognized multiple failures of the system as described in the prior paragraphs. See also specific citations above. 12

14 Another issue with these earlier national average trend data is the fact that they belie stark regional, rural-urban, and socioeconomic variations. According to a report published by FMoH in 2004, infant and child mortality in the North West and North East zones were in general twice the rate in the southern zones, while the MMR in the North West and North East were six times and nine times respectively the rate of 165/100,000 recorded in the South West zone. 18 In 2008, 90 percent of the births in the North West zone and 87 percent of the births in the North East zone occurred at home. 19 These substantial regional variations as well as rural-urban variation and variation by socio-economic status are reflected in MCH health outcomes of interest, including MMR and under-five mortality rates, which are shown in Table 1 below. Figure 4. Percent of Live Births Attended by Skilled Health Personnel in Nigeria ( ) Source: Nigeria Demographic and Health Survey Table 1. Variation in MMR and Under-Five Mortality Rates within Nigeria (2008) Rate Subgroup MMR* 1,549 North East 165 South West 828 Rural 351 Urban Under-Five Mortality** 219 Lowest wealth quintile 87 Highest wealth quintile 18 Federal Ministry of Health (2004) Health Sector Reform Program: Strategic Thrusts and Log Framework Abuja: Federal Ministry of Health. As cited in TWG-NSHDP/Health Sector Development Team, July Nigeria Demographic and Health Survey 2008 data as cited in Federal Republic of Nigeria, Federal Ministry of Health, Save the Children, JHPIEGO (2011) 13

15 * Maternal mortality per 100,000 live births ** Under-five mortality per 1,000 live births Source: Nigeria Demographic and Health Survey 2008 as cited in Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA (2012) A further complication when attempting to understand the SBA trend data is that, due to rapid population growth, Nigeria s reported slow increase in SBA utilization rates may mask a relatively large increase in the reported absolute number of SBA-attended births. According to a 2012 study called Countdown to 2015: Maternal, Newborn, & Child Survival, between 1990 and 2008, the absolute number of births attended by skilled health providers in Nigeria doubled from approximately 1.3 million in 1990 to 2.7 million in Had the number of births remained stable each year between 1990 and 2008, coverage would have reached around 63 percent in 2008, 24 percentage points higher than the actual figure of 39 percent. 20 This challenge of increasing the proportion of SBA utilization while the population is itself growing quickly illustrates the types of pressures Nigeria faces, particularly in light of the continued rapid grown in population expected in the next few years. Nigeria s Reported SBA Utilization Trends Relative to Broader Trends. According to the data discussed above, and considering all of the aforementioned caveats, Nigeria s reported increases in SBA utilization rates were mirrored by regional and global increases in SBA utilization of roughly the same proportion. However, Nigeria s rates continued to be lower than the rates in most neighboring countries (see Figure 5) despite the fact that Nigeria is a relatively wealthy country [pain point]. Figure 5. MDG Indicator 5.2: Proportion of Births Attended by Skilled Health Personnel (Nigeria and Neighboring Countries) 20 Countdown to 2015: Maternal Newborn & Child Survival (2012). Building a Future for Women and Children: The 2012 Report 14

16 Source: United Nations Statistics Division. Millennium Development Goal Indicators. Data downloaded May 2013 from: Data are not available for all years, and notable variations in trend lines (from increasing to decreasing utilization rates) are reflected in the data reported for nearly all of these countries, including Nigeria. Source: United Nations Statistics Division. Millennium Development Goal Indicators. Data downloaded May 2013 from: Note: Data are country adjusted. Data not available for all years for all countries. Additional information about data sources is provided on the data download page. Trends in SBA utilization at the global and Sub-Saharan African levels also suggested that Nigeria was behind, relatively speaking (see Figure 6) [feedback loop]. In the developing world, where maternal and child mortality rates are the highest, all regions showed improvement in the proportion of assisted births, from 55 percent in 1990 to approximately 65 percent in (The most recent national data for Nigeria were for 2008, when the reported rate was 39 percent, as already discussed.) These and other global and regional trend data spanning two decades are provided in Table 2. Figure 6. Skilled Birth Attendants: Comparison of Utilization Rates (World, Sub-Saharan Africa, and Nigeria) ( ) Source: UN (2012). Millennium Development Goals Report Statistical Annex. Table 2. Progress Toward MDG Goal 5 Indicator 5.2: Proportion of Births Attended by Skilled Health Personnel 21 Source: UN (2012). Millennium Development Goals Report, Statistical Annex. 15

17 Percentage of births attended by skilled health personnel World Developing Regions Northern Africa Sub-Saharan Africa Latin America and the Caribbean 1/ Eastern Asia Southern Asia Southern Asia excluding India South-Eastern Asia Western Asia Oceania Caucasus and Central Asia Developed Regions Least Developed Countries (LDCs) / Includes only deliveries in health care institutions Source: UN (2012). Millennium Development Goals Report Statistical Annex. Through 2008, Nigeria was not only falling short of its own hopes and potential; it was also not on track to meet Millennium Development Goals (MDGs) 4 or 5, stoking pressure to deliver better results. (Annex 3 provides reported trend data for Nigeria and neighboring countries for indicators associated with MDGs 4 and 5.) 4. A NEW PARADIGM EMERGES, 2009-PRESENT Amid growing pressure to improve, both from within and outside of Nigeria, a new approach to programs intended to improve MCH including the utilization of SBAs emerged in 2009 after the arrival of new leadership at the FMoH National Primary Health Care Development Agency (NPHCDA) [inflection point]. Programs aimed at saving the lives of mothers and babies by increasing SBA 16

18 utilization and promoting antenatal care, among other MCH interventions, have been tested and improved upon since The Government of Nigeria has invested deeply in the recent improvements in MCH program design and delivery. The FMoH, with support from President Jonathan, has launched ambitious large-scale efforts that are designed, funded, and implemented by Nigerians, in particular the Midwives Service Scheme (MSS), the Subsidy Reinvestment and Empowerment Programme (SURE-P) MCH, and the Saving One Million Lives (SOML) Initiative. The Government of Nigeria has also been consulting with its international partners on these programs. Figure 7 summarizes this evolution, which is explored in more detail below. Figure 7. Evolution of Programs Intended to Promote SBA Utilization and Other MCH Service Th e O l d Paradigm Th e New Paradigm: Significant shift toward delivering maternal and child health outcomes; utilizing best-in-class research to inform program design; iteratively improving design and implementation with experience and evidence of what is/is not working building impact MSS & SURE-P MCH build on each other, are implemented simultaneously now under umbrella of Save One Million Lives (by 2015) 4.1 Dr. Muhammad Ali Pate becomes Director of the National Primary Health Care Development Agency (NPHCDA) Launch of the Midwives Service Scheme (MSS). Early results indicate positive, but uneven improvements; adjustments made to approach Launch of the Subsidy Reinvestment and Empowerment Programme Maternal and Child Health (SURE-P MCH) Launch of Save One Million Lives, which incorporates and scales up several MCH programs New Leadership A senior leadership team at NPHCDA designs evidence-based programs to focus on delivery of MCH outcomes. President Jonathan reelected; Dr. Pate promoted to Minister of State for Health Launch of the Nigeria State Health Program Investment Project (NSHIP) Impact Evaluations of SURE-P MCH, NSHIP, and other programs underway Many of the same team members are now in charge of MSS, SURE-P MCH, and Save One Million Li One step toward the new paradigm took place in 2008, when Dr. Muhammad Ali Pate left his post as a Senior Health Specialist at the World Bank in Washington, D.C. to return to Nigeria and become Director of the NPHCDA. According to all experts interviewed for this case study, Dr. Pate quickly catalyzed a change in culture and approach to primary health care, particularly MCH. He repositioned the NPHCDA to target new MCH interventions that were based on learning from experience (including mistakes) and on evidence [inflection point]. As put by one senior health expert in Nigeria, the new leadership brought about a culture shift [within FMoH] of accountability. Dr. Pate s post at NPHCDA was intended to last only one year, but he agreed to stay on for an additional two years. In 2011, in 17

19 recognition of Dr. Pate s work, President Jonathan nominated Dr. Pate to serve as the Minister of State for Health, a position he held until July 2013, when he returned to the U.S. after five years of service. Dr. Pate has not single-handedly spearheaded the recent changes, even though his leadership is widely recognized as a critical catalyst. The transformation of programs designed to save the lives of mothers and babies was and still is the result of hard work of many individuals and organizations. A core staff leadership team at the FMoH, including Dr. Ugo Okoli and Dr. Kelechi Ohiri, has been instrumental in designing, delivering, and improving these programs. Implementing partners at state and local agencies, as well as international partners, donors, and experts from around the world have contributed. Several of the core leadership team that has been involved since 2008 is still in place, working on the ongoing implementation of these ambitious programs. 4.2 The Midwives Service Scheme (MSS) In 2009 the NPHCDA established the Midwives Service Scheme (MSS), a collaborative effort between the three tiers of government to facilitate an increase in the coverage of SBAs. The program s targets for 2015 are based on increasing access to services and the capacity building of health workers (see Figure 8). Figure 8. Midwives Service Scheme: 2015 Targets Reduction of maternal and newborn mortality by 60% in MSS Facilities Increasing access to services Capacity building of health workers Design. MSS involves hiring newly graduated, unemployed, or retired midwives to work temporarily in rural areas in all 36 states and the FCT, with an emphasis on underserved areas. The midwives are posted for one year (with an opportunity to renew their engagement if they so wish) to select PHCs. These are linked through a cluster model in which four such PHCs with the capacity to provide basic essential obstetric care are clustered around a secondary care facility that can provide comprehensive emergency obstetric care. A midwife is deployed to each selected PHC with the intent of offering 24- hour provision of MCH services and access to skilled attendants at all births. In recognition of the state and local responsibility for primary health care, NPHCDA instigated the signing of memorandums of understanding (MOUs) between the NPHCDA, state governments, and local 18

20 governments to support MSS implementation coupled with co-financing from states to pay the participating midwives. Where needed, the MOUs also provided for midwife housing. Implementation. Implementation began in the fall of After one year, 2,488 midwives had been deployed to 652 designated PHCs in 36 states and the FCT. 22,23 Monitoring data comparing July- December 2009 data with data from the same time period in 2010 recorded at least a 50 percent 24 increase in utilization of SBAs and a decrease in MMR of 26 percent at MSS facilities nationwide, though regional improvements in both service utilization and health outcomes were uneven. 25,26 During the first year of implementation, several challenges with MSS implementation became apparent, including: Availability and regional deployment of midwives, particularly where the need had been the greatest, in the northeast and northwest zones [pain point]. Most of the available, trained midwives came from the southern part of the country, and some stakeholders speculated about political motivations for deploying these midwives in the northern regions. There was also concern that uneven deployment of midwives in the northern part of the country would not be equitable to those in the other parts of the country, despite the data that clearly indicated that the need was greatest in the north. These and other obstacles about availability and placement were improved upon over the first few years of implementation. Midwife attrition, a common problem with this type of intervention [pain point]. Many of the midwives are from the south working for MSS in the north. A large number of recently trained midwives (44 percent of all deployed) are recent graduates of midwivery school who are early in their own careers and the establishment of their own families, incentivizing their return to their own communities. Lack of social amenities, language barriers between the midwives and the local community, and working in hard-to-reach rural areas have also contributed to attrition. Inconsistent local implementation of the MOUs signed between NPHCDA and state and local governments, resulting in issues such as a lack of agreed-upon housing for the midwives and irregular or delayed salary payment by state and local governments [pain point]. 27 Secondary market sales of essential drugs and equipment supplied to PHCs for MSS, but subsequently not available for use when needed for this reason [pain point] Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA (2012) 23 Additional details about the MSS design are provided in an article written by the health officials noted above who designed MSS, including Dr. Pate. See reference and link to Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA (2012) in Annex 1, References. 24 Data shown in Exhibit 5 indicate a 74 percent increase during this time period. Previous reported data (see Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA, 2012) indicated an increase closer to 50 percent. 25 The national MMR increased overall from 572 per 100,000 to 789 per 100,000, though MSS participating facilities in the North East and South East zones. The facility-based neonatal mortality ratio (NMR) in the same period in 2010 was 9.3 per 1,000 compared to per 1,000 live births for the same period in Facilities in the NE, NW, and SW did not show a decrease in NMR when compared to Federal Republic of Nigeria, FMoH (2013a) 27 Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA (2012) 28 DIME SURE-P MCH concept note (2013) 19

21 Even in areas where antenatal visits and SBA utilization increased at MSS facilities, a majority of women still opted to deliver their babies at home without SBAs, leading officials to question whether deliveries that did occur at the MSS facilities reflected a higher proportion of high-risk pregnancies more likely to result in death or injury due to late transfer to the PHCs. The NPHCDA identified several strategies to overcome these challenges, including creating more attractive pay packages; provision of ambulances, accommodations, and health insurance coverage for the midwives; provision of an additional 1,000 community health workers to hard-to-reach areas in the northern zones; and a long-term plan to identify and train locals to become midwives who will then work within their own communities [adaptation/refinement]. There was also some discussion of whether to provide supervised home delivery as part of the MSS to better reach women who participate in antenatal care at PHCs but choose to deliver at home. NPHCDA identified several longer-term needs as well, including training the midwives in other aspects of care such as prevention of mother-to-child transmission of HIV (PMTCT) and family planning, and increasing capacity for utilization of information and communications technology. They also identified a need for capacity building of the PHC team beyond just midwives [adaptation/refinement]. SBA Utilization and Outcomes. According to the Federal Ministry of Health, between , the reported utilization of SBAs at MSS facilities continued to increase substantially (150 percent from 2009 rates), as did increases in the uptake of antenatal care visits (over 100 percent increase from 2009 rates, though there was a decrease in utilization of these services between ) [behavior change]. By the end of 2012, the monitoring data indicated an overarching decrease in MMR of 47 percent since 2009 across MSS facilities in all six zones [feedback loop]. 29 (See Figure 9.) In October 2012, MSS received the 2012 Commonwealth Association for Public Administration and Management International Innovations Award that honors public service innovation by recognizing organizations that have made significant contributions to improving governance and services in the public sector. 30 The awards panel noted that MSS innovation by Nigeria has changed the understanding and analysis of similar challenges in other countries. 31 Nevertheless, the utilization and outcome data come from monitoring efforts only, which are not able to establish any causal relationships with the MSS program. Unfortunately, MSS represents a lost opportunity for undertaking a rigorous outcome evaluation that could identify what components of MSS have and have not worked since implementation began. During the first years of MSS, Dr. Pate (at the time still the Director of NPHCDA) requested assistance from the World Bank s Development Impact Evaluation group to work with the MSS team to design an evaluation that would help to identify any changes in SBA utilization or MNCH outcomes attributable to MSS. 32 The MSS team participated in an impact evaluation (IE) workshop hosted by the Bank s evaluation group in Cape Town in December However, by that time, the MSS design was already fixed, removing the option of introducing variations in the MSS treatment to see how the program could be designed to function more 29 ibid. 30 See: DIME 20120: SURE-P MCH Impact Evaluation Concept Note and Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate, MA. (2012). 20

22 effectively. Officials interviewed for this case study indicated that, in hindsight, they wished they had built a rigorous IE into the actual design and implementation of MSS [pain point]. They recognize that the monitoring data alone are not sufficient for understanding if, why, or how MSS has made a difference, and for using that information to further improve MSS s effectiveness. Figure 9. Monitoring Data for the First Three Years of MSS Implementation ( ) Figure 9a. Deliveries by Skilled Birth Attendants at MSS Facilities ( ) Figure 9b. Total Antenatal Care Visits in MSS facilities (2009 to 2012) 21

23 Figure 9c. MSS - Trends in Facility Based Maternal Mortality Rates per 100,000 Live Births Source: Federal Republic of Nigeria, Federal Ministry of Health. Expanding Access: Reaching the Hard to Reach Insights from the Saving One million Lives Initiative. Dr. Muhammad Ali Pate, Minister of State for Health, Nigeria. Presentation given at the Women DELIVER Conference May 28, The Government of Nigeria also recognized that MSS was only a beginning both in terms of its scope and in terms of trying a new targeted, evidence-based approach to program design. As put by one official in Nigeria: During Pate s time the MSS came about to accelerate reductions in maternal and child mortality rates and to see if Nigeria could achieve MDGs 4 and 5. MSS was noticed by the world, and we won an award, but it couldn t cover all services. It was like a drop of the ocean, providing services in only 1,000 facilities out of over 25,000. We wanted to learn some lessons from that to increase antenatal coverage and actually delivery in facilities, which was still a problem. MSS is still being implemented as of the fall of New Programs Build Upon MSS. Two programs launched after MSS aim to increase SBA utilization as well as other core indicators of MCH: the Nigeria State Health Investment Project (NSHIP) and SURE-P MCH. Both of these newer programs, described below, intend to improve MCH outcomes by improving upon MSS [inflection point], using additional evidence to support new program design, and taking comprehensive yet targeted approaches to broad MCH service delivery, including but not limited to increasing utilization of SBAs. The discussion below focuses on the SBA components of these two new simultaneously occurring interventions, considering that improvements in SBA utilization must be done in the larger context of other supporting MCH systems. While both MSS successor programs are compelling examples of the evolution of delivery around SBA utilization, SURE-P MCH is particularly so because it is a program designed, funded, and implemented entirely by the Government of Nigeria itself. Finally, a third program, the Save One Million Lives Initiative (SOML), is the most recent government program aimed at reducing maternal and neonatal mortality [inflection point]. SOML is an umbrella program incorporating several public health interventions, including SURE-P MCH, MSS, and several other MCH initiatives. Several of the programs under the SOML umbrella are engaging in IE work to 22

24 generate evidence of effectiveness as these programs are being implemented all signifying the shift to the new delivery paradigm. 4.3 The Nigeria State Health Investment Project (NSHIP) In 2010, acknowledging that widely dispersed programs that invest small amounts in many facilities were unlikely to yield results, the World Bank initiated a new project in collaboration with FMoH, state, and local officials to make more targeted and strategic improvements to MCH services to improve their impact. The Bank decided to design a new program to achieve meaningful results by both building upon lessons from MSS (and other MCH programs) and incentivizing results where implementation occurs, namely at local health facilities (PHCs). This new program is based on a premise that mechanisms intended to improve quality health care services must be introduced at the health care facility, which is the direct link to the pregnant women themselves [adaptation/refinement]. Accordingly, the new program was designed to strengthen accountability and introduce a set of incentives to improve care quality at PHCs. NSHIP has as its primary objective to increase the delivery and use of high-impact MCH interventions and improve quality of care at selected health facilities in the three participating states (Adamawa, Nasarawa, and Ondo) and LGAs. NSHIP has two components, results-based financing, and technical assistance. 33 Utilization of SBAs at pilot implementation facilities is one key indicator of NSHIP s effectiveness, but several other indicators related to performance outcomes are also tracked, including the proportion of month-old children fully immunized, and the proportion of primary health facilities having essential medicines and commodities in stock Two RBF approaches are being used: (i) Performance Based Financing for outputs at health facilities and LGA PHC Departments and (ii) Disbursement Linked Indicators at state and LGA levels. In addition, the project will test a separate decentralized facility financing at the health facility level as an alternative to the financing, whereby facilities will receive fixed output-based payments without performance-linked incentives. The technical assistance is comprised of three subcomponents: (i) strengthening of states project implementation capacity; (ii) support to federal, state, LGA and facility levels to manage and operate the RBF approach; and (iii) overall project management activities, as well as monitoring and evaluation (M&E) activities aimed at providing independent assessment of results and building national capacity for M&E. 34 Other indicators include (as examples): average health facility quality of care score, number of outpatient visits by children under five, and number of direct project beneficiaries. Source: The World Bank. June Implementation Status & Results: Nigeria States Health Investment Project (P120798). Report No: ISR Accessed: 23

25 Figure 10. Coverage of Services in NSHIP LGAs (December 2011-December 2012) Source: The World Bank Group, Africa Team and the Federal Ministry of Health, Nigeria (April 2013). Nigeria State Health Investment Project (NSHIP): Success, challenges and lessons learned. PowerPoint presentation. NSHIP began implementation in December of 2011, and results reported through the first 13 months of implementation are encouraging (see Figure 10). According to the trends reflected in monthly reports, births attended by SBAs have risen from 10 percent in December 2011 to 39 percent one year later [feedback loop]. In some PHCs, institutional delivery was reported to be nearly 60 percent at the end of 2012, reflecting significant increases from one year earlier. 35 Significant improvements in coverage of antenatal care have been seen on the whole. The decrease in antenatal care between November and December 2012 is reported to be related to delayed incentive payments; however, it is unclear why this delayed payment would not have had the same effect on the other indicators if the influence was that immediate. Notably, postnatal care still remains low. An impact evaluation (IE) of NSHIP has been built into the program s design from the beginning [inflection point]; however, implementation of the IE was held back until 2013 due to the delay in the approval of the borrowing plan by the National Assembly [pain point]. The IE design calls for equalizing the average amount of funding between health facilities that receive results-based financing (RBF) and their comparisons. The comparisons consist of a set of facilities that will receive so-called Decentralized Facility Financing or DFF but that do not participate in the PBF program. The IE involves randomly assigning the Local Government Areas (LGAs) to DFF or PBF conditions, as well as evaluating the impact against the purely non-funded control case. 36 A baseline survey for the IE was scheduled to commence in October 2013 and the final results are expected in Personal communication with World Bank official. (June 18, 2013) 37 Personal communication with World Bank official (September 9, 2013) 24

26 4.4 SURE-P MCH: An Ambitious Program Designed, Funded, and Implemented by the Government of Nigeria In 2011, President Jonathan won reelection under a Transformation Agenda intended to address a lack of government continuity, consistency, and commitment to agreed policies, programs, and projects. The Transformation Agenda for provides direction for the current administration based on a set of priority policies and programs intended to transform the Nigerian economy to meet the future needs of the Nigerian people. 38 The Subsidy Reinvestment and Empowerment Programme (SURE-P) is part of the Transformation Agenda. SURE-P is a program intended to improve the lives of Nigerians by increasing spending from a new government fund derived from a partial withdrawal of a fuel subsidy that the government implemented in January 2012 [inflection point]. 39 SURE-P funds supplement the routine national budget to improve results in targeted SURE-P project areas: MCH (including increases in SBA utilization), roads and bridges, Niger-Delta, railways, mass transit, vocational training, and public works. SURE-P is overseen by a committee whose mandate from the President is to deliver service with integrity and restore people s confidence in the government. 40 The SURE-P MCH Programme aims to build upon the lessons from MSS and other MCH programs implemented over the past several years to reduce maternal and newborn mortality rates and accelerate progress toward achieving MDGs 4 and 5. (See Textbox 3 for a list of the SURE-P MCH care package components). The NPHCDA is responsible for the implementation of SURE-P MCH, which covers all 36 states and the FCT, focusing on rural areas and underserved communities. Pregnant women and newborns residing in rural and underserved communities are the target groups. Design. SURE-P MCH is divided into supply- and demand-side components (see Table 3) that intend to build upon MSS as well as additional evidence about effective delivery of these kinds of programs. On the supply side, SURE-P MCH aims to recruit, train and deploy a total of 5,400 midwives and 4,000 Textbox 3. The SURE-P MCH Care Package Focused antenatal care services Skilled birth attendants Post-natal care and immunization Family planning/child spacing Free supply of MNCH drugs Free supply of medical equipment Free supply of commodities such as Village Health Worker kits and MAMA kits Deployment of Midwives and CHEWS at SURE-P Health Facilities Reactivation of Ward Development Committees Engagement of Village Health Workers Renovation of Health Centers Conditional cash transfers (CCTs) to pregnant women in pilot sites Source: Republic of Nigeria. SURE-P MCH Project Office. Mobilizing Access to Health Care Services for Mothers and Infants (MAMA). Issue 1. April Federal Republic of Nigeria 39 The subsidy withdrawal was unpopular with many Nigerians who saw fuel prices more than double overnight on January 1, 2012, when the government initially eliminated the fuel subsidy altogether. Public frustration was exacerbated by a deep mistrust of the government, and doubt that the government would spend the funds saved from withdrawing the subsidy to better the lives of everyday people. Social unrest broke out and unions enacted strikes until the government compromised by partially reinstating the subsidy. 40 Republic of Nigeria. SURE-P MCH Project Office. Mobilizing Access to Health Care Services for Mothers and Infants (MAMA). Issue 1. April

27 Community Health Extension Workers (CHEWs) to supplement the provision of midwives alone with more than twice as many health workers. SURE-P MCH is hiring and training 12,000 village health workers to establish the connection between the PHCs and pregnant women in each village by It began providing upgrades to infrastructure and a guarantee of adequate provision of supplies and equipment to PHCs starting at the end of These changes reflect supplementary provisions in the availability of broader basic health services recognized as gaps under MSS. Similarly, SURE-P MCH addresses low utilization of PHCs and SBAs by introducing demand-side components to increase accessibility and utilization of MCH services [adaptation/refinement]. Conditional cash transfers (CCTs), an approach to creating behavior change by paying people in exchange for specific behavioral actions and information provision, 41 are the two major demand-side interventions. CCTs have been shown to successfully reduce poverty, encourage parental investments in the health and education of their children, and catalyze other behavior changes. 42,43 CCT payment is provided in four independent and successive stages: N1,000 upon registration in a PHC; N1,000 after completing standard antenatal visits; N2,000 upon institutional delivery; and N1,000 after zero-dose immunization is given to the newborn baby. The amount of these payments (N5,000 or approximately US$32) are expected to more than offset the costs of institutional deliveries and antenatal visits. Payment will be made through traditional banking and mobile technologies. 44 SURE-P MCH implementation is occurring in two phases. In Phase I, the supply side of the intervention is being implemented in 500 PHCs. Implementation of Phase I began in 2012 and the first birth under the program occurred in June The official launch of the CCT program took place in May 2013, though CCT implementation, including payouts to participating women, began in In Phase II, the CCT component will be added and the supply side will be expanded to 1,300 facilities by Information dissemination activities target all women of reproductive age to encourage them to register with their nearest PHC. 42 DIME SURE-P MCH Concept Note, For a literature review on the evidence associated with CCTs, see Fiszbein, Schady et al. (2009) and other published studies referenced in the World Bank s Development Impact Evaluation s SURE-P MCH Impact Evaluation Concept Note, April DIME SURE-P MCH Concept Note,

28 Table 3. SURE-P MCH Overview Scope: Nationwide (36 States and Federal Capital Territory) 500 PHCs in first stage; scale-up to 1,300 by 2015 Supply Side - Recruitment, training and deployment of 5,400 midwives, 4,000 CHEWs, and 12,000 VHWs in needy communities - Provision of essential supplies, commodities, and refurbishment of PHC infrastructures - Provision of monetary and non-monetary incentives to reduce health workers attrition - Monitoring the availability of supplies at the PHC level Demand Side - Conditional Cash Transfer: pregnant women given a total cash payout of N 5,000 (~ US$32) conditional on attending antenatal care, skilled birth attendance, and postnatal care - Informational outreach for awarenesscreation and demand promotion Source: DIME SURE-P MCH Impact Evaluation Concept Note, April SURE-P MCH is also involving traditional birth attendants (TBAs), who are individuals with no particular similarities in skills or approaches to providing support for pregnant women or the delivery process. Some TBAs have no formal training whereas others are unemployed or retired midwives. TBAs attend many home births in Nigeria, particularly in poor and rural communities where the need is greatest for SBAs. Moreover, they also tend to be trusted more by the community than public providers, with whom many patients have not had good experiences. PHCs often are understaffed and undersupplied, and even SBAs serving at PHCs share a reputation with other PHC staff as being rude or otherwise disrespectful to patients. In contrast, TBAs tend to be well known individuals who are long-standing members of the community. SURE-P MCH is involving TBAs by encouraging them to be engaged as village health workers, and providing a stipend for referrals to PHCs for antenatal care and deliveries. According to FMoH officials, some TBAs are taking up this offer. First Six Months of SURE-P MCH Implementation. During the first year of implementation, SURE-P MCH recruited 6,630 health care workers, including 1,304 midwives, 2,254 community health extension workers, and 3,072 female village health workers across the six geopolitical zones of the country. These workers have been deployed to provide quality antenatal, skilled birth delivery at birth and post-natal services for previously underserved rural, poor women accessing maternal, neonatal and child health services in 500 SURE-P supported PHCs across the 36 states and FCT. All of the midwives have undergone a refresher training both theory and clinical (practical) training on life saving skills (basic emergency obstetric care) and helping babies breathe training. Monitoring data suggest that SURE-P MCH has generated a 19 percent increase in update in antenatal care and a 9.5 percent increase in the utilization of SBAs at the PHCs in communities hosting them (see Table 4) [behavior change] FMOH, NPHCDA SURE-P MCH progress report August

29 Table 4. SURE-P MCH Monitoring Data After First Six Months of Implementation ( ) Total ANC Visits New ANC Visits No. of Deliverie s No. of New Acceptors for Family Planning No. of Family Plannin g Visits No. of Post natal Visits Before SURE-P MCH started April - Sept ,503 51,807 16,695 11,176 26,292 25,870 (6 months) After SURE-P MCH started October Feb 2013 (5 months) Percentage Increase from baseline 154,133 61,623 18,285 14,987 29,190 26,338 10% 19% 9.5% 34% 11% 2% One of the strongest components of SURE-P MCH is the integration of IE into its design and learningbased phases of implementation (see Annex 5) [inflection point]. DIME is carrying out the evaluation in collaboration with researchers from the University of Sussex and University College London. The Bill and Melinda Gates Foundation and the World Bank s Strategic Impact Evaluation Fund, which is financed by the UK s Department for International Development, are funding the evaluation. This IE, with a budget of approximately US$2.5 million over five years, is being undertaken in close collaboration with the SURE-P MCH Implementation Unit at the NPHCDA. The agency funding and implementing SURE-P MCH has welcomed input from DIME and the Bill and Melinda Gates Foundation on the project s design, and is supportive of having the IE built into implementation throughout the course of the program. Moreover, the DIME evalution team has helped to inform the actual design of SURE-P MCH through the provision of evidence in support of particular design features and close collaboration with the NPHCDA SURE-P team on design and implementation plans (see Textbox 4). This is an unusual role for impact evaluators, and it is one that is more likely to support improvement in program design and delivery throughout the entire lifecycle of the SURE-P MCH program, even if it also Textbox 4. Cornerstones of the DIME Approach to IE DIME promotes prospective IE, an evaluative process planned before implementation (or expansion) of the intervention that measures results during and after implementation. Working prospectively has many advantages: 1. Informs design. Researchers that are brought in early contribute by sharing existing evidence and modifying the design of the intervention. 2. Stimulates critical thinking. The policy maker can set the agenda for the evaluation and pose the policy and operational questions that she finds more important to answer. 3. Develops robust designs. The analytical design can be developed to answer the questions of interest, and good opportunities found in the rollout to improve the analytical validity of the evaluation. 4. Helps plan for data collection. Early engagement offers the opportunity to plan for needed data collection and align monitoring and evaluation data requirements Affects decisions in real time. Evaluations that accompany the interventions can provide feedback during implementation to improve results, not only measure results at the end. It can also be used to track the trajectory of results over time to help us understanding causal transmission, nonlinearities, reversals and sustainability patterns.

30 means that the evaluators are not entirely independent from the program itself [adaptation/refinement]. Ongoing Prospects. SURE-P MCH is designed to address many of the challenges seen during the old paradigm. These include introduction of a highly targeted program that is not only based around a known public health intervention that can have dramatic impacts, but that also incorporates lessons from its predecessor, the MSS. The entire SURE-P MCH package (of which the SBA component is one part) addresses the previous problems associated with lack of essential supplies and lack of care quality through midwife retention incentives. The design includes mechanisms to increase demand for SBA services through CCTs. In addition, it builds in rigorous IE from the outset in a way that has already resulted in strengthening program design through pre-testing and focus groups that are informing the types of incentives that should be tested to know what to scale up later. All of these signals bode well for improved delivery and impact as part of the new paradigm. There are, however, still many challenges and obstacles to overcome, including issues with accountability at multiple levels of government, challenging political and security contexts in certain parts of the country, and the reality that changes to long-standing approaches to health care delivery will take time to name a few. Also, despite the CCT for pregnant mothers and education programs aimed at increasing incentives for mothers to participate in the program, it is unclear whether the program includes enough demand side features to truly drive up participation by mothers in those areas of greatest need. Finally, despite some work to integrate private health care into the longer-term strategies at the federal levels, SURE-P MCH itself does not appear to address the prominent role of private health care facilities. Given that in parts of Nigeria over half of all primary health care is provided by private facilities or providers, it is unclear if and how SURE-P MCH intends to improve MCH services at these facilities, or perhaps simply drive demand away from private providers by increasing demand at PHCs. 4.5 The Most Recent Chapter: The Save One Million Lives (SOML) Initiative In October 2012, President Jonathan committed the Government of Nigeria to the Saving One Million Lives (SOML) initiative, which has a 2015 deadline. Reasons cited by the Government of Nigeria for undertaking SOML include poor health outcomes compared to other countries with similar levels of resources, along with inequitable distribution of health outcomes and utilization of health services, including a nearly eight-fold difference between the wealthiest quintile and poorest quintile in access to skilled birth attendance at delivery. 46 SOML is country-driven and country-led but is implemented in close collaboration with several partners from the development agencies, philanthropies, and civil society organizations. With a budget of nearly US$2.8 billion through 2015, SOML is funded by the Government of Nigeria with additional support from the governments of Norway and France; the World Health Organization; the Global Alliance for Vaccines and Immunizations; State Governors; UNICEF; the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the European Union; and others. 46 Federal Republic of Nigeria (2012). SOML confidential draft program document. 29

31 SOML is comprised of eight components: Improving maternal, newborn and child health; improving routine immunization coverage and achieving polio eradication; elimination of mother-to-child transmission of HIV; scaling up access to essential medicines and commodities; malaria control; improving child nutrition; strengthening logistics and supply chain management; and promoting innovation and use of technology to improve health services. The component targeting improved maternal, newborn and child health is focused on delivering an integrated package of interventions at 5,000 PHCs to increase the SBA utilization rates (as well as the coverage of four ANC visits) to 80 percent by 2015 (see Table 5, SOML Targets for ANC and Facility Delivery). Table 5. Save One Million Lives Targets for ANC and Facility Delivery Targets ANC 45% 57% 68% 80% Facility Delivery 35% 47% 58% 70% Source: Federal Republic of Nigeria, FMoH (August 2012). SOML Draft Program Document The Office of the Minister of State for Health estimates that the maternal, newborn, and child health interventions that are part of SOML (including SURE-P MCH, as noted below) have the potential to save up to 662,900 lives by 2015, of which there are 16,800 maternal lives, 180,800 neonatal lives, 465,300 post neonatal and child lives by Through saving these lives, this component of SOML aims by 2015 to reduce MMR from 545/100,0004 to 250/100,000 live births and NMR from 40/1,0004 live births to 14/1,000 live births. 47 SOML includes SURE-P MCH as a major source of programmatic design and funding for this component of SOML. SURE-P MCH comprises an estimated US$500 million of the targeted US$575 million budget for this component of SOML ( total). SOML is targeting a scale up of PHCs staffed SBA, from 4,300 PHCs targeted by SURE-P MCH to 5,000 PHCs targeted under SOML. 48 SOML also adds additional program efforts beyond those covered under SURE-P MCH. For instance, SBAs as well as care providers within the communities will be trained in techniques covered by a separate Helping Babies Breathe initiative to increase skills in neonatal resuscitation and reduce the incidence of birth asphyxia and neonatal deaths. On the whole, SOML reflects a bold commitment to improving MCH outcomes through specific, known interventions with clear targets [inflection point]. The stakes for President Jonathan and FMoH are high, at least politically speaking. The next presidential election is scheduled for 2015, and the President s reelection prospects will depend largely on whether the public gains trust in the government, and whether they can see tangible benefits from the petroleum subsidy reduction implemented in The success of SOML will also determine whether Nigeria will meet MDGs 4 and 5. Finally, it will test 47 Ibid. 48 Ibid. Note also that the 4,300 PHCs targeted under SURE-P MCH include 2,000 PHCs still considered to be part of MSS according to some (but not all) reports. It is unclear whether the split between the two programs (MSS and SURE-P MCH) that comprise the 4,300 targeted PHCs is material to this case. 30

32 whether a new paradigm of healthcare service delivery based on evidence and learning from experience can dramatically improve health outcomes for mothers and newborns in a pivotal African nation. At the same time, to presume that the hard work in terms of program design and implementation and the underlying changes in culture and behavior that these programs aim to influence is now addressed would be wildly naïve. Nigeria will continue to face immense public health challenges for years to come, and these programs as ambitious and strategic as they are will only prove themselves in as much as they improve MCH outcomes by directly and convincingly saving the lives of mothers and babies. In the long run, there are nevertheless positive signals thus far that more lives will be saved as the current programs are implemented and then adapted, based on experience and evidence of what works. Moreover, the support for the ongoing impact evaluations suggests a willingness both to innovate and to be held accountable for achieving results. The prospects are clearly worth tracking and learning from over the next several years, as the results of these programs become apparent. As stated in May 2013 by Dr. Precious Gbenol, Senior Special Advisor to the President on the Millennium Development Goals: Our work is not done until we demonstrate impact. We must produce incontrovertible evidence and benchmark against well-articulated goals and benchmarks LESSONS FROM THE CASE STUDY This case study has described in detail the evolution of the SBA-related programs aimed at saving the lives of mothers and babies in Nigeria, from 1999 to the present. The main service delivery lessons address the questions posed at the outset of the case study. These questions are repeated below, followed by the pertinent findings. Q1. What changes have been made to programs intended to save the lives of mothers and babies in Nigeria, from 1999 to the present? The health care paradigm in Nigeria between the reestablishment of democracy in 1999 and 2008 focused on building a primary health care system using a one size fits all approach regardless of differences in need or economic or cultural context. The overly uniform approach was one of several challenges that hindered effective health care delivery during this period, which did not produce major improvements in MCH indicators, including the utilization of SBAs. Nigeria s progress in these areas fell short of regional and global averages [pain point], and Nigeria was not on track to meet Millennium Development Goals 4, (Reduce Child Mortality), or 5, (Improve Maternal Health). A new paradigm emerged with new leadership at the Federal Ministry of Health and the introduction of the Midwives Service Scheme (MSS) in 2009 [inflection point]. MSS reflected a significant shift toward an outcome-focused, evidenced-based MCH program devoted to increasing the availability and utilization of SBAs. Despite several challenges and uneven improvements in MCH outcomes during the first two year of implementation, after three years of MSS implementation ( ), monitoring reports indicate that the utilization of SBAs at MSS facilities had increased by 150 percent and maternal mortality rates (maternal deaths per 100,000 live births) had fallen by 47 percent nationwide [behavior change]. Still, MSS s ongoing challenges indicate that additional work is needed on both the supply and 49 Remarks made at the May 2013 launch of the SURE-P MCH CCT Programme. 31

33 demand sides of programs intended to increase SBA utilization, and that these programs must be part of a broader set of MCH system improvements. Three more recent programs launched between 2010 and 2012 built upon lessons from MSS: The Nigeria State Health Investment Project (NSHIP), the Subsidy Reinvestment and Empowerment Programme MCH effort (SURE-P MCH), and Save One Million Lives (SOML). Save One Million Lives has incorporated both MSS and SURE-P MCH under its programmatic purview and goal of saving one millions lives mostly mothers and babies by These new programs utilize both experience and additional evidence to support program design. They take comprehensive yet targeted approaches to broad MCH service delivery including (but not limited to) increasing utilization of SBAs. Q2. How have the newer programs drawn from learning and adaptation from research evidence and earlier experiences? Less than satisfactory experiences with the earlier programs, from 1999 to 2008, led to the need for starting afresh. At the same time, the new programs benefited from a strong commitment to use evidence-based designs. 5.1 Lessons from the Old Paradigm By 2008, the Government of Nigeria and its supporters from the international development, philanthropic, and civil society communities recognized that the collective efforts were largely ineffective, and a major shift in approach was needed to deliver results and deliver them at scale. Experts interviewed for this case study, including FMoH officials working on program design and implementation during these years, agree that many lessons could have been learned from the experience during these years to more quickly and effectively adapt and improve. For example, the one size fits all approach to primary health care delivery continued to be taken regardless of regional disparities in MCH trends, contexts, and need. Moreover, the health-care delivery hierarchy split between the different levels of government remained largely uncoordinated. Funding and services often did not reach the targeted recipients, and when they did the poor quality of care most often did not lead to increased demand and utilization. A lack of accountability at all levels of government was considered to be a problem. There were missed opportunities to analyze the relationships between programs and outcomes, leaving a lack of evidence regarding what did and did not work that could be used to inform future program design. Textbox 5 summarizes these and other challenges to delivery that were identified during this period. 32

34 By 2008 it was clear that an unacceptably high number of mothers and babies were still dying or suffering other negative effects of a lack of basic care, that Nigeria was not on track to meet its MDGs 4 and 5, and that a paradigm shift was needed [pain point]. Textbox 5. Summary of Challenges to Delivery During the Old Paradigm One size fits all approach to primary health care that did not account for differences in need or context by region, rural-urban split, socioeconomic status, culture, etc. Lack of targeted programs focused on specific interventions (such as SBA utilization) demonstrated to have the potential for substantially improving health outcomes Overemphasis on infrastructure without commensurate provision of skilled staff, basic amenities (water, power, etc.) and needed drugs and supplies Poor quality of care Lack of coordination between federal, state, and local agencies Funding and resources that often did not reach intended end user Lack of accountability (related to previous) Shortage of skilled SBAs particularly in areas with the greatest need Lack of analysis of what interventions worked/did not work Missed opportunities to learn from experience and utilize evidence from other countries to improve program design and delivery 5.2 Evidence-Based Designs The new programs benefited from explicit efforts to identify appropriate, evidence-based designs. MSS. To begin with, MSS was designed by Dr. Pate, Dr. Ugo Okoli, Dr. Mohammed J. Abdullahi, and other health experts at NPHCDA. 50 These experts used lessons from the Afghanistan community midwife program, which had recently catalyzed a rapid increase in the number of deliveries by SBAs. 51 This program and others were described in research studies published in the Lancet s Maternal Survival Series on 2006 on strategies for reducing maternal mortality. 52 The series concluded that the main obstacles to expansion of maternity care were scarcities of skilled providers and health-system infrastructure, substandard quality of care, and women s reluctance to use maternity care where there are high costs and poorly attuned services. Based on the results of simulations published in this study, teams of midwives and midwife assistants working in facilities could increase coverage of maternity care by up to 40 percent by The experts also drew from a study in the New England Journal of Medicine on evidence produced from a study on the rapid expansion of the health workforce in 50 Including Dr. Seye Abimbola, Dr. Ugo Okoli, and Dr. Olalekan Olubajo, all of NPHCDA. 51 UNICEF (2008); Walsh (2007) 52 Campbell, OM and Graham WJ (2006) 53 Koblinsky, M et al. (2006) 33

35 response to the HIV epidemic. 54 The resulting MSS program design was intended to introduce an initial evidenced-based, targeted program that would address critical gaps in access to SBAs [inflection point]. NSHIP. Similar efforts marked the design of specific aspects of NSHIP. For this program, the World Bank commissioned Oxford Policy Management to research what would be required for a new results-based approach to financing of Primary Healthcare Centres (PHCs) to be effective, including an examination of who cares about results and what challenges might occur along the chain of responsibility and flow of resources. 55 They found examples in Pakistan and Latin America that were used by the Bank to inform the design of NSHIP. SURE-P MCH. For SURE-P MCH, a critical element involved the design of the Conditional Cash Transfers (CCTs), and the specific design elements for the CCTs were based not only on MSS experience and evidence on the effectiveness of CCTs from other studies, but also from a pre-pilot study in the field undertaken by SURE-P MCH staff in April and May of Pretesting conducted by the SURE-P MCH staff team involved interviews with pregnant women and focus group discussions with women, health workers, and Ward Development Committee members. 56 These targeted focus groups and baseline surveys are informing the types of incentives that will be implemented and tested as SURE-P implementation rolls out [feedback loop]. 57 At the same time, the design of SURE-P is using a distinctive evidence-based design process that involves the impact evaluators from the World Bank s Development Impact Evaluation Group (DIME). The approach taken by DIME to IE is unusual in a way that may very well help to support improved service delivery, not only for SURE-P MCH, but also for NSHIP and the other 17 IEs being undertaken in Nigeria in close collaboration with and with support from the Government of Nigeria [inflection point]. Unlike traditional IEs, which purposely keep a distance from the efforts they are evaluating to be as independent as possible, DIME staff get involved wherever possible from the earliest stages to support evidence-based program design and implementation, not only to learn about impact retrospectively. In other words, the DIME IE approach is to intentionally become part of the policy/program intervention to enhance program strength, promote critical thinking, and provide interim feedback during program 54 Samb, B, et al. (2006) 55 According to the study s final report, executive summary: The report sets out the findings of a Problem Driven Political Economy and Institutional Assessment of the World Bank s proposed NSHIP, which seeks to introduce RBF for PHC in Adamawa, Nasarawa and Ondo states. The study addresses the following issues:(i) Whether RBF can improve the responsiveness of providers and enhance the use of public primary care facilities (or more generally, the quality and quantity of care provided); (ii) To identify who will support and who will oppose the proposed RBF project at different levels of government; (iii) To determine the potential governance challenges in the implementation of RBF; and (iv) Whether the existing institutions in the selected states can effectively manage the RBF. Source: Oxford Policy Management (2011). 56 DIME SURE-P MCH Concept Note, In the spring of 2013, two targeted focus groups were conducted across six selected states located in five of the six geopolitical zones of the country. Findings concluded that Nigerian midwives are passionately interested in their work and that introduction of both monetary and non-monetary rewards may provide a good opportunity for addressing the high attrition rate of Midwives. Also, there is the need to follow-up on state government s commitments towards the MoU, particularly in addressing issues related to accommodation. A recurring point from all the states is the issue of community appreciation. (Omoluabi E, Akinyemi, A (2013).) These findings are being incorporated into the next phase of the IE to rigorously test which incentives work in practice. 34

36 implementation, not only ex post [adaptation/refinement]. The formative role epitomizes an evidencebased approach to program design. SOML. Finally, SOML is a sector-wide approach to improve health outcomes, focusing on proven, evidence-based, cost-effective interventions that address the leading causes of morbidity and mortality. 58 As described by the FMoH, SOML reflects a paradigm shift toward outcomes, as opposed to mostly focusing on inputs and processes [inflection point]. 59 The Office of the Honorable Minister of State for Health explains that, The status quo is an obstacle to success, an obstacle to making Nigeria s people healthier and saving lives. Excellent policies and programs designed will not lead to an improvement in outcomes without strong execution and dramatic innovation in the way health programs are delivered. 60 Overall, and across all these later programs, the high-level of commitment by public health officials in Nigeria to learning from experience and to utilizing evidence to inform public health program design and delivery is remarkable. Comments like the following from a senior FMoH official reflect the change in culture and delivery taking place: 2015 is when the [current] administration ends. We will have changed the conversation from thinking only about inputs to about outputs. The next time we get together we won t be talking about how many hospitals we ve built but how many lives we ve saved. To skeptics who believe that change is simply impossible, a senior FMoH official observed: People are going to have their own opinions and that s fine. However, the government is us. When we have the midwife who s treating patients or the health care inspectors, we are them. We have to be somewhere. This is an unprecedented amount of effort money in health care reform. You can be cynical about anything, but that should not prevent you from seeing the opportunity to do something right and doing it. 6. HOW THE CASE STUDY INFORMS THE SCIENCE OF DELIVERY During the fall of 2013, the Bank (in collaboration with members from academia) conducted an analysis on case study work in development in the context of science of delivery. The emerging framework identifies five elements that are seen as important factors enabling science of delivery approaches. The present case study reveals those five elements, or a subset thereof, as follows: Focus on measurable welfare gains of citizens. The Midwives Service Scheme MSS, the first of four programs related to the utilization of skilled birth attendants (SBAs), started in 2009 and was still being implemented by the end of the case study in From , monitoring reports indicated a 150 percent increase in the utilization of SBAs, and a decline of 47 percent in maternal mortality rates nationwide. However, formal impact evaluations of the SBA initiatives were still underway by the end of the case study, so there is as yet no evidence of improved welfare among the people the project aimed to help. 58 Ibid. 59 Federal Republic of Nigeria (2012a). SOML. Draft PowerPoint presentation. 60 Federal Republic of Nigeria (2012). 35

37 Multi-sector, interdisciplinary, multi-stakeholder approaches and partnerships. The service delivery programs have served multiple stakeholders by addressing the needs of both supply- and demand-side constituents, such as the pay packages and health insurance coverage for the SBAs, the refurbishing of the public health centers, and conditional cash transfers for the service clients. The programs also have been developed in close collaboration with partners from development agencies, philanthropies, and civil society organizations. Use of evidence to inform experimentation, learn, adapt, and to measure results. The SBA initiatives were designed in an evidence-based manner, with reviews of, and lessons learned from, similar initiatives that had been implemented elsewhere as well as in Nigeria. The successive initiatives also filled knowledge gaps to inform the development of the newer programs, as in the identification of various incentive schemes to address the issue of retaining midwives. Change management, leadership, and learning from practitioners. New Ministry of Health leadership starting in 2009 led to a markedly different service delivery strategy, moving away from an earlier one size fits all primary health care strategy that had ignored regional disparities, contexts, and needs. However, the case study does not discuss how learning from practitioners might also have taken place. Being adaptive, flexible, and iterative when implementing solutions. The programs have exhibited adaptation and flexibility by addressing the challenges created by the country s regional variations. For instance, the programs have created different incentives for deploying SBAs in high-need regions. 36

38 ANNEX 1. REFERENCES Abdulraheem I. S., Olapipo A. R. and Amodu M. O. Primary health care services in Nigeria: Critical issues and strategies for enhancing the use by the rural communities. Journal of Public Health and Epidemiology Vol. 4(1) (2012): Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA (2012) The Midwives Service Scheme in Nigeria. PLoS Med 9(5): e doi: /journal.pmed Adeniyi. J, Ejembi CL, et al. (2001) The Status of Primary Health Care in Nigeria: Report of a Needs Assessment. Survey. National Primary Health Care Development Agency. Bankole, A, et al. (2009) Barriers to Safe Motherhood in Nigeria. Guttmacher Institute. Campbell OM, Graham WJ (2006) Strategies for reducing maternal mortality: getting on with what works. Lancet 368(9543): Chukwu, C.O. Onyebuchi, Honorable Minister of Health, Nigeria (2011). Maternal, Newborn and Child Health in Nigeria: Where Are We Now? PowerPoint presentation. 10/28/2011 Countdown to 2015 (2012) Countdown to 2015: Maternal Newborn & Child Survival. Building a Future for Women and Children: The 2012 Report. de Janvry, A, Sadoulet, E University of California at Berkeley and World Bank Development Economics Research Group (2005) Conditional Cash Transfer Programs for Child Human Capital Development: Lessons Derived from Experience in Mexico and Brazil. Federal Republic of Nigeria, FMoH (2013a). Expanding Access: Reaching the Hard to Reach Insights from the Saving One million Lives Initiative Dr. Muhammad Ali Pate, Minister of State for Health, Nigeria presentation given at the Women DELIVER Conference May 28, 2013 Federal Republic of Nigeria, FMoH (2013b). NSHIP Impact Evaluation. Draft PowerPoint presentation given at the May 2013 Impact Evidence and Action to Save Lives in Nigeria workshop sponsored by the World Bank s Development Impact Evaluation group. Federal Republic of Nigeria, FMoH (2013c). National Primary Health Care Development Agency. Subsidy Reinvestment and Empowerment Programme (SURE-P) MCH Program. August 2013 Progress Report. Federal Republic of Nigeria, Federal Ministry of Health, Office of the Honorable Minister of State for Health (2012). Saving One Million Lives Accelerating improvements in Nigeria s Health Outcomes through a new approach to basic services delivery. Program Document. (Review Draft) August 13, 2012 Federal Republic of Nigeria, Federal Ministry of Health, Save the Children, JHPIEGO (2011). Saving Newborn Lives in Nigeria: Newborn health in the context of the Integrated Maternal, Newborn, and Child Health Strategy. Abuja: 2nd edition. 37

39 Federal Republic of Nigeria, National Population Commission & ICF Macro (2009) Nigeria Demographic and Health Survey Federal Republic of Nigeria (2011?) The Transformation Agenda Summary of Federal Government s Key Priority Policies, Programmes and Projects. Fiszbein, A., Schady, N., Ferreira, F., Grosh, M., Kelleher, N., Olinto, P., Skoufias, E. (2009). Conditional cash transfers: reducing present and future poverty. Policy Research Report, The World Bank - Washington DC. Koblinksy M, Matthews Z, et. al (2006) Going to Scale with Professional Skilled Care. Lancet 368 (9544): Legovini, A (2010) Development Impact Evaluation Initiative: A World Bank-Wide Strategic Approach to Enhance Developmental Effectiveness. The World Bank Group. Development Impact Evaluation Initiative Omoluabi E, Akinyemi, A. Centre for Research Evaluation Resource and Development (2013) Influencing Midwife Retention Strategies for the Nigeria Subsidy Reinvestment Empowerment Program (SURE-P MCH). Final Report. 18 July, Oxford Policy Management (2011) Political Economy And Institutional Assessment For Results Based Financing For Health. Final Report. Samb B, Celletti F, Holloway J, Van Damme W, De Cock KM, et al. (2007). Rapid expansion of the health workforce in response to the HIV epidemic. New England Journal of Medicine 357(24): Sowunmi FA, et al. (2012) The Landscape of Poverty in Nigeria: A Spatial Analysis Using Senatorial Districts-level Data. American Journal of Economics 2(5): TWG- NSHDP/Health Sector Development Team. July The National Strategic Health Development Plan Framework ( ) NCH Adopted. UNICEF. Afghanistan s Community Midwives. December United Nations (2013) Millennium Development Goals Report Statistical Annex. United Nations Population Fund (UNFP). Skilled Attendance at Birth. Accessed June 30, 2013, UN Statistics Division, About the Millennium Development Goals Indicators. Retrieved June 30, 2013, from Walsh, Declan. (2007) Afghanistan's Midwives Tackle Maternal and Infant Health. The Lancet, Vol. 370 (9595) (2007): 1299 October

40 The World Bank Group (2012). Report No: ICR477 Implementation Completion And Results Report (Ida Uni And Uni) On Credits In The Amounts Of SDR Million (US $127.0 Million Equivalent) And SDR 57.3 Million (Us$90.0 Million Equivalent) To The Federal Republic Of Nigeria For A Health Systems Development Project II. December 7, Human Development Sector Health, Nutrition and Population (AFTHW) Country Department 1 AFCW2) Africa The World Bank Group, Development Impact Evaluation Group (2013). SURE-P MCH Impact Evaluation Concept Note. The World Bank Group (2013). Implementation Status & Results: Nigeria States Health Investment Project (P120798). Report No: ISR The World Bank Group, Africa Region Human Development; Federal Ministry of Health, Nigeria, National Primary Health Care Development Agency; & Canadian International Development Agency (June 2008). Nigeria: Improving Primary Health Care Delivery -- Evidence From Four States. Report No NG The World Bank Group, Africa Team (2013). Nigeria State Health Investment Project (NSHIP): Success, challenges and lessons learned. PowerPoint presentation. The World Bank Group (2009). Reducing maternal mortality: strengthening the World Bank response. Population and reproductive health policy report. Yakoob, M.Y. et al. The effect of providing skilled birth attendance and emergency obstetric care in preventing stillbirths. BMC Public Health, 11(Suppl 3) (2011):S7 Yemisi I. Ogunlela. An Assessment of Safe Motherhood Initiative in Nigeria and the Achievement of the Millennium Development Goal Number 5. The Social Sciences, 7(2012):

41 ANNEX 2. A BRIEF HISTORY OF NIGERIAN GOVERNMENT AND LEADERSHIP The Federation of Nigeria was granted full independence from Great Britain in October In January 1966 army officers overthrew the government and assassinated the prime minister and the premiers of the northern and western regions. The country briefly returned to democracy between 1979 and 1983 under President Shehu Shagari. Subsequently, military regimes and civil unrest continued until May 1999 when the re-emergence of democracy ended 16 consecutive years of military rule. Former military head of state Olusegun Obasanjo, freed from prison by Abubakar, ran as a civilian candidate and won the presidential election. He was reelected in In the 2007 general election, Umaru Yar'Adua and Goodluck Jonathan, both of the People's Democratic Party, were elected President and Vice President, respectively. The election was marred by electoral fraud, and denounced by other candidates and international observers. In November 2009, Yar'Adua fell ill and was flown out of the country to Saudi Arabia where he remained until shortly before his death in May In February 2010, Goodluck Jonathan began serving as acting President in the absence of Yar Adua. Goodluck Jonathan called for new elections and stood for re-election in April Substantial political and social unrest in northern parts of country in the past few years led the President to issue a state of emergency in three northeastern states in May

42 ANNEX 3. PROGRESS TOWARD MDGS 4 AND 5 (SELECT INDICATORS): NIGERIA AND NEIGHBORING COUNTRIES In September 2000, leaders from 189 nations agreed on a vision for the future that took the shape of eight Millennium Development Goals (MDGs), which provide a framework of time-bound targets for 2015 by which progress can be measured. 61 MDG 5 is Improve Maternal Health by 2015, with a target of reducing the global Maternal Mortality Ratio (MMR) by three-quarters between 1990 and MDG 4 has two indicators related to this target: MMR (Indicator 5.1) and proportion of births attended by skilled health personnel (SBAs) (Indicator 5.2). Figure A3-1. MDG Indicator 4.1 Under Five Mortality Rate: Nigeria and Neighboring Countries ( ) Source: United Nations Statistics Division. Millennium Development Goal Indicators. Data downloaded May 2013 from: Figure A3-2. MDG Indicator 4.2 Infant Mortality Rate: Nigeria and Neighboring Countries 61 UN Statistics Division, About the Millennium Development Goals Indicators. Accessed June 30, 2013, 41

43 Note from source: Some of the MDG data presented here have been adjusted by the responsible specialized agencies to ensure international comparability, in compliance with their shared mandate to assess progress towards the MDGs at the regional and global levels. Figure A3-3. MDG Indicator 5.1 Maternal Mortality Ratio: Nigeria and Neighboring Countries Notes from source: 42

44 These countries lack complete registration but registration and/or other types of data are available Original data source: Trends in Maternal Mortality: WHO/UNICEF/UNFPA/WB Some of the MDG data presented in this website have been adjusted by the responsible specialized agencies to ensure international comparability, in compliance with their shared mandate to assess progress towards the MDGs at the regional and global levels. 43

45 ANNEX 4. FUNDING FOR MATERNAL, NEWBORN, AND CHILD HEALTH IN NIGERIA Improving MCH outcomes in Nigeria has been a priority for the international community for years. According to the Countdown to 2015 study, Nigeria receives more official development assistance for maternal, newborn and child health than any other country, amounting to nine percent of all development assistance in MCH globally (see Figure A4). The same study also points out how absolute amounts of assistance are not synonymous with support per capita within vulnerable populations. When adjusted for the size of the vulnerable populations, Nigeria received US$12.28 per live birth in 2009 as compared to US$17.88 in Ethiopia or nearly US$63.40 in Afghanistan 62. Narrowing the data further to only maternal and newborn health, India received the most official development assistance in absolute terms, but only US$4.89 per live birth, compared with US$14.24 in Nigeria and $27.24 in Ethiopia. These disparities are further complicated by subnational variations in utilization in urban and rural locations and socioeconomic groups. 63 Figure A4. Top Ten Countries Receiving Official Development Assistance for Maternal, Newborn and Child Health (2009) Source: Creditor Reporting System Aid Activities Database of the Organisation for Economic Cooperation and Development Assistance Committee. [As reproduced in Countdown to 2015 report.] 62 Note for future draft: Unclear from source report whether this is the correct interpretation of the reference to Afghanistan. This reference may apply to one of the related statistics. 63 Countdown to 2015: Maternal Newborn & Child Survival (2012). 44

46 While the international community has invested deeply in MCH in Nigeria, the investment of the Government of Nigeria has been far greater, comprising over 95 percent of all funding for MCH. 64 In other words, even the large financial investment made from international donors pales in comparison with what Nigeria itself has invested in this area. Still, by the government s own estimates, Nigeria s expenditures on health have been modest on a per capita basis compared to other parts of Africa, both in absolute terms and as a proportion of gross domestic product. 65 In 2010, the government reports total health expenditure per capita US$63 as amounting to about percent of GDP. 66 Nigeria appears again in this respect to face the challenge of having a large (and rapidly growing) population, which offsets the otherwise seemingly high levels of investment in the health sector. 64 Senior official within FMoH, and senior official at the World Bank. Personal communications May & June Government of Nigeria SOML program report World Development Indicators as reported in Government of Nigeria SOML program report

47 ANNEX 4. ONGOING IMPACT EVALUATION WORK IN NIGERIA SEPTEMBER 2013 Sector IE Title 1. Agriculture Linking Farmers to Infrastructure: Impact Evaluation of Nigeria s Commercial Agriculture Development Project 2.* Environment Rebuilding Landscapes and Lives: Impact Evaluation of the Nigeria Erosion and Watershed Management Project Contact persons Abuja DC Status Lucas Akapa Nandini Krishnan Baseline analysis Amos Abu 3. Education Kano Girls' Education CCT Olatunde Adekola 4. Education Re-Kindle-ing Learning: E- Olatunde Readers in Lagos Adekola 5. Education Nigeria Partnership for Olatunde Education Project (NIPEP) Adekola, M 6. FPD Enhancing ICT skills for the Business Process Outsourcing (BPO) Industry 7. FPD Learning in the Use of New Financial Products: The Case of Credit Cards 8. FPD Savings Promotions and Financial Inclusion 9. FPD Story of Gold: Entertainment as a nudge to promote responsible saving and borrowing Abul Azad Michael Wong Michael Wong Michael Wong Michael Wong 10. FPD YouWiN! Impact Evaluation Michael Wong 11. Health Enlisting community volunteers and patent medicine vendors in M Abul Azad Vincenzo Di Maro, Marcus Holmlund Shwetlena Sabarwal Shwetlena Sabarwal Marie-Helene Cloutier, Marcus Holmlund Kevin Croke Martin Kanz Martin Kanz Vincenzo Di Maro & Aidan Coville, David McKenzie, Marcus Holmlund, Design Final analysis Final analysis Pre-design Final analysis Intervention Follow-up data collection ongoing Final analysis 1st follow-up survey analysis completed Baseline analysis 46

48 the fight against malaria 12. Health National Sex Work HIV Prevention Program IE F. Ayodeji Akala Marelize Gorgens Design 13. Health State Health Program Investment Credit (Results- Based Financing) 14. Health SURE-P Maternal and Child Health Program 15. Health Dramatic Evaluations: Impact Evaluation of the MTV series Shuga 16. Health Quality enhancement for primary health care services 17. Health Prevention of mother-to-child transmission of HIV 18. Health Logistics and procurement for primary health care services 19. Legal Accessing Justice to Settle Disputes 20. Social Protection 21. * Life Skills and Apprenticeships for Youth Employment (YESSO) Transport Rural Access Mobility Project 2 (RAMP 2) * IDA 16 commitment IE Oluwole Odutolu Christel Vermeersch Pre-baseline Olufemi Marcus Baseline Adegoke Holmlund M Abul Azad Victor Orozco Pre-baseline M Abul Azad Felipe Dunsch Baseline Olufemi Adegoke Olufemi Adegoke Foluso Okunmadew a Mohammed Aliyu Marcus Holmlund Marcus Holmlund Nicholas Menzies, Vincenzo Di Maro Patrick Premand Mohammed Essakali Pre-design Pre-design Design Design Intervention; IE CN review pending The ongoing IE work in relation to SURE-P MCH (see Row 14) illustrates how impact evaluations have been designed and are being used. The SURE-P MCH IE aims to answer several questions, including what the overall impact of SURE-P MCH is on SBA utilization and use of antenatal care (ANC). 67 The IE is 67 The specific IE research questions (and their associated outcomes and impacts to be measured) are: (1) Overall programme: What is the overall impact of SURE-P on skilled birth attendance and use of antenatal care? (2) Supply-side intervention: midwives incentives and community-based stock monitoring: (2.1) What is the impact of non-economic incentives on midwives attrition? (2.2) What is the impact of monetary incentives on midwives attrition? (2.3) What is the additional impact on midwives attrition of the provision of monetary incentives, over and above non-economic ones? (2.4) Regarding monetary incentives: provided that the yearly amount paid is the same, does it matter (in terms of midwives attrition) whether the tranches paid increase or are constant over time? (2.5) What is the level of monetary incentives that produces the same effect on attrition as non-economic ones? (2.6) What is the effect on drug stockouts of a combined intervention that: informs communities of the available antenatal and obstetric health services; subsequently elicits stockout rates at the local health centres from telephone surveys of pregnant women; finally disseminates this information on stockout rates in the communities benchmarking such information to stockout rates in the facilities available to other communities. (3) 47

49 designed to measure both overall impact of SURE-P MCH as a package and separate contributions of each program component to identify which components work and should be scaled up, and which should be redesigned or discontinued. The overall structure of the IE is shown in Figure A5 below. In Phase I, randomized experiments will be comparing the impact of midwife incentives: non-monetary incentives, monetary incentives, and no incentives (control group). Five hundred SURE-P PHCs organized into clusters of four PHCs per cluster are part of the Phase I experimental design. These groups will test the efficacy of monetary and non-monetary incentives. Separately, community stock incentives versus a control group with no such incentives are being compared in Phase 1. In Phase II, an additional 800 PHCs will be added to the experimental design as well as a comparison of incentive combinations, such as midwife incentives and CCTs. In Phase II, a quasi-experimental analysis will also be conducted to determine the overall effectiveness of the SURE-P MCH program by comparing outcomes at treatment facilities with control facilities matched based on similar trends in key indicators. 68 Demand-side intervention (CCT): Over and above the effect of the supply side interventions, what is the additional impact on the uptake of skilled birth attendance and antenatal care of a CCT that give mothers a cash transfer conditional on these outcomes? Source: The World Bank Group DIME (2013) SURE-P MCH Impact Evaluation Concept Note. 68 Ibid. 48

50 Figure A5. Design of the SURE-P MCH Impact Evaluation Source: The World Bank Group DIME (2013) Several things are remarkable about the work being undertaken to integrate IE into healthcare programs in Nigeria. First, this work reflects a culture shift and reorientation toward results-oriented policies and programs, consistent with the paradigm shift realized over the past few years. Second, the sheer number (21) of IEs planned or already being implemented (see the initial table in this Annex) reflects collaboration between health experts at the federal and state levels in Nigeria and several development partners including those who convened or sponsored the May 2013 Impact Evidence and Action to Save Lives in Nigeria workshop (the World Bank, Bill and Melinda Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and the World Bank administered Africa Regional Learning Program). Third, but most importantly, it was clearly apparent from the enthusiastic participation of the 80 federal and state experts who participated in the May 2013 Impact Evaluation to Save Lives in Nigeria workshop that there is a commitment in Nigeria to improving health care effectiveness using rigorous methodologies that would lead to improved results. These individuals and the agencies and programs they oversee are deeply committed to improving the welfare of Nigerians, and they are learning critical tools that will help them to understand what interventions do and do not work. 49